Basic Information
| Provider Information | |||||||||
| NPI: | 1356339659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDBUD PHYSICAL REHABILITATION PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Practice Location | |||||||||
| Address1: | 4008 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224278 | ||||||||
| FaxNumber: | 9186224844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 05/05/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 9186224126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200034500H | 05 | OK | MEDICAID | 700522061 | 01 | OK | MEDICARE | OTHER | 200034500A | 05 | OK | MEDICAID | CJ4389 | 01 | MEDICARE RAILROAD | OTHER | 200034500E | 05 | OK | MEDICAID | 200034500B | 05 | OK | MEDICAID | 200034500F | 05 | OK | MEDICAID | 200034500I | 05 | OK | MEDICAID | 200034500A | 01 | OK | MEDICAID LEGACY | OTHER | 200034500D | 05 | OK | MEDICAID | 200034500C | 05 | OK | MEDICAID | 200034500G | 05 | OK | MEDICAID |